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Version 1.7 Commercial Building Permit May 15, 2000
4
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION -'TO BE: COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ... ..... . a _.. _ ._� .. _. ._ _ _ _�._ _ _wu m _ �,� _.u_ ..... __r .. as Owner of the subject property
hereby authorize '.,_.__a __.._._ ... __ ...... _m .._._ m._ w_ - -- _ _ ..._ __ .. _.- - to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I,
as Owner /Authorized
Agent hereby declare that the statements and information on the foreg ng application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains . and penalties ofer
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION: SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder ::—,.,--..
License Number
Address Expiration Date
Signature Telephone
SECTION 13 - WORKERS' COMPENSATI INSURANCE AFFIDAVIT (M.G.L. c-152: 25C(6)}
Workers Compensation Insurance affidavi, must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 No
J
The Commonwealth of Massachusetts
- Department of In dustrial Accidents
Office Investigations
A.
w ff o f
It
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information / Please Print Legibly
Name ( Business /Organization/Individual): AVn 4 44 ^tide d AIN�Q
Address: 6 b e Cyr k SA-
City/S tate/Zip: Or 7 Phone #: `�l 3 rc) -
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer 4. E] I am a general contractor and I
with 6. ❑ construction
employees (full and/or part- time).* have hired the sub - contractors
2,_I am a sole proprietor or partner- listed on the attached sheet. 7: ❑Remodeling
ship and have no employees These sub-contractors have g Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
�. ❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we h . ave no
_ 11M Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 -a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si gnature
Phone #
Of use only. Do not write in this area, to be completed by city or town official
— City `or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Versiont.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11)
In dependent Str uctural Engineering Structural Peer Review Required Yes O No O
SECTION 11 - OWNER AUTHORIZATION,, TO BE COMPLETE EN
OWNERS AGENT OR CONTRA T S FOR BUILT I RMIT
PG AA-
as Owner of the subject property
hereby authorize G � 42- i' " / to
act on my half, in all ma a ativ rk..authorized by this b ' ng permit application.
AAA ( 7 13 z
S' nature Date
as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
N d * - A a no -C' 1 /V et'
Print Name
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Constructio Supervisor / Not Applicable ❑
Name of License Holder : (40 (4 n
nQ a. c 1 1 0 � 7
License Number
6 6 C Id 17 7 �S/3( /)
Address Fpiraf Date
C) --3��
Signature Telephone
SECTION 13 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes Q No O
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable O
Name (Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 ��General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
6 6(""k
Address
�/,,
, -- L_—__ � W's � 5 v - 3 , ) L� 2
Signature Telephone
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONIRZ
Existing Proposed Required by Zoning
nis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DONT KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 36,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additio ing ❑
Exterior Alteration ❑ Existing Ground Sign ❑ New Signs ❑ Roofing C g of U Other
Brief Description Enter a brief description here. C dd ' I d v A d r•, f s
Of Proposed Work: U LTe t'n c✓� rn # v f C� 0 7 l h c . (a � bri a
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A ❑
A-4 ❑ A -5 ❑ 113
❑
B Business ❑ 2A ❑
E Educational ❑ 2B I ❑
F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B
M Mercantile ❑ 4 ❑
R Residential ❑ R - 1 ❑ R - 2 ❑ R - 3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (so
1st 1st
2nd 2 nd
3 r 3'
0 4d'
Total Area (so Total Proposed New Construction (sf)
Total Height (ft)
Total Height It
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7 Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone[] Municipal ❑ On site disposal system[]
ties
7 7
...
Versionl.7 Commercial Building Permit May 15, 2000
� D Department use only
� CC ity of Northampton Status of Permit:
G uilding Department Curb Cut/Driveway Permit -
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
No Ompton, MA 01060 Two Sets of Structural Plans
7 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address _
q This section to be completed by office
oZ � /�}d L, y & K E s 7 ' Map Lot Unit
4/OR T�/f}s�PTN � Zon Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record ''//
C y�,q /R , <wl ECiNSK I
Name (Print Current Marling Address: .i,1 rd--?
Signature ` - Telephone - 5
2.2 Au or' ed A Dent:
Name (Print) IV a ka k,� Current Mailing Address: 46 C �a� 2 ds
rraef I rn e P
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by rmit applicant
1. Building ! `�Gc7 (a) Building Permit Fee
2. Electrical C S�� (b) Estimated Total Cost of
Construction from 6
3. Plumbing /� Building Permit Fee
4. Mechanical (HVAC) (J
5. Fire Protection
6. Total = 0 +2+3+4+5) 2`( of Check Number A di gym
This Section For Official Use On
Building Permit Number Date
Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0097
APPLICANT /CONTACT PERSON NATHANAEL ALMEKINDER
ADDRESS/PHONE 66 CLARK ST EASTHAMPTON (413) 250 -3007
PROPERTY LOCATION 28 HOLYOKE ST
MAP 32C PARCEL 218 001 ZONE URC(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out -1
Fee Paid
Typeof Construction: INSTALL REPLACEMENT WINDOWS & ADD KITCHEN SUPPORT BEAM &
GENERAL REPAIRS -WINDOW LABEL MUST BE ON FOR INSPECTION I: NVERT
., . . . _ . .<. .
kf L&MRY RM, CABINETS &DOORS #28 1ST -& 2ND FLR UNITS s._m
" dew Coristruc tion
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 102079
3 sets of Plans / Plot Plan
THE FOL ., 40WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I FO ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
on Delay
e of uilding Official Date
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.